Incidence of Gestational Diabetes
Mellitus in Pregnant women from Rural Background Attending Antenatal
Care Clinic
Gupta K1, Parmar M2,
Dubey S3
1Dr Kumud Gupta, Associate professor, 2Dr Meenal Parmar, Post Graduate
student, 3Dr Smarika Dubey, Postgraduate student. All are affiliated
with Department of Obstetrics and Gynaecology, NIMS, Jaipur, Rajasthan,
India
Address for
correspondence: Dr Meenal Parmar, Email:
dr.meennalparmar@gmail.com
Abstract
Objective:
To assess the incidence of Gestational Diabetes Mellitus in pregnant
women from rural background attending antenatal care clinic. Introduction:
Gestational diabetes mellitus (GDM) is defined as any degree of glucose
intolerance with onset or first recognition during pregnancy. Incidence
of GDM is increasing worldwide for recent trends in obesity and
advancing maternal age, with huge healthcare and economic costs.
Depending on the population studied and the diagnostic test employed,
prevalence may range from 2.4 to 21 per cent of all pregnancies. Method: 75 gm OGTT
was performed on pregnant women attending antenatal clinic in NIMS
Medical College and Hospital, Jaipur, Rajasthan, incidence then
calculated. Result:
Out of 511 patients studied, maximum percentage of patients with GDM
(42.85%) were seen in age group of >/= 36 years, followed by
31-35 years (9.84%). Incidence of GDM in rural area of Jaipur in our
study was 03.32%. Conclusion:
Of total 511 patients 17 patients were diagnosed to have Gestational
Diabetes Mellitus thus incidence came out to be 3.32%. Out of these 17
GDM patients, 3 (17.64%) patients were diagnosed in first trimester and
thus diagnosing pregnant patients with high risk factors in first
trimester, proved to be beneficial as early diagnosis and treatment
reduces maternal and fetal complications. Association of presence of
risk factors and GDM was not statistically significant and would have
missed 13 (76.47%) patients.
Keywords:
Oral Glucose Tolerance Test, Gestational Diabetes Mellitus
Manuscript received: 25th
Oct 2014, Reviewed:
20th Nov 2014
Author Corrected: 27th
Nov 2014, Accepted for
Publication: 15th Dec 2014
Introduction
Gestational diabetes mellitus (GDM) is defined as any degree of glucose
intolerance with onset or first recognition during pregnancy. Incidence
of GDM is increasing worldwide due to recent trends of increasing
obesity and advancing maternal age [1]. Diagnosis requires a
75 g oral glucose tolerance test (OGTT) which is carried out
between the gestation of 24 and 28 weeks, in all women not previously
found to have overt diabetes or GDM, with the baseline level of
92 mg/dL, 180 mg/dL at 1 h, and
153 mg/dL at 2 h from glucose load as cut-offs.
To diagnose GDM, it is sufficient that only one of these thresholds is
equalled or exceeded [1].
Depending on the population studied and the diagnostic test employed,
prevalence may range from 2.4 to 21% of all pregnancies [2].
Women exposed to GDM are at high risk for pregnancy complications,
future type 2 diabetes mellitus (DM), and cardiovascular diseases.
There are several evidences indicating risk factor for adverse
pregnancy outcomes for mothers and their offspring related to
increasing maternal glucose levels, whereas treatment to reduce
maternal glucose levels reduces this risk. Based on these evidences, to
identify women at risk for adverse pregnancy outcomes and improve
prognosis through evidence-based interventions, recent tight diagnostic
criteria for GDM have been introduced by the International Association
of the Diabetes and Pregnancy Study Groups (IADPSG). In Indian context,
screening is essential in all pregnant women as there is eleven fold
increased risk of developing glucose intolerance during pregnancy
compared to caucasian women [3]. The recent data shows that the
prevalence of GDM in our country is 16.55%. Hence universal screening
is important in our country.
Aims
and Objectives
• To access the incidence of Gestational Diabetes
Mellitus in pregnant women from rural background attending antenatal
care clinic and indoor of Obstetrics and Gynaecology department of NIMS
Medical college and Hospital, Shobha Nagar, Jaipur , Rajasthan.
• To determine the outcome, in relation to glucose
intolerance for mother and fetus both.
Material
and Method
Our study was prospective study, carried out on pregnant women
attending antenatal care clinic and indoor of the Department of
Obstetrics and Gynaecology of NIMS Medical College and Hospital
,Jaipur, Rajasthan for a period of one year from September 2011 to
august 2012, on 511 pregnant women, approved by Institutional Ethical
Committee.
Inclusion criteria:
1. All healthy, singleton pregnant patients who gave consent
for the oral glucose tolerance test.
2. Indian origin.
Exclusion criteria:
All other conditions causing elevated glucose levels were excluded, like
1. Known case of diabetes mellitus
2. Known case of chronic diseases causing hyperglycemia
3. Pregnant patients taking drugs causing hyperglycemia.
At first antenatal visit, detailed history, physical examination and
routine investigations were done. Assessment of risk factor for GDM was
done by following classification:
As per ADA (American Diabetes Association)
1. High Risk: Women
falling under this category was asked to come the next morning in a
fasting state so as to undergo 75 gm oral glucose tolerance test. 75 gm
glucose tolerance test was repeated at 24-28 weeks for those high risk
pregnant women whose test was negative at first antenatal visit.
2. Average and Low risk:
Women falling under this group were asked to come at 24-28 weeks period
of gestation to undergo same test.
ADA Diagnostic criteria for 2h -75 gm OGTT, if two or more of following
values meet or exceed the threshold,
Fasting Plasma glucose-95mg/dl
1 Hour Plasma glucose-180mg/dl
2 Hour Plasma glucose- 155mg/dl
Treatment was indivisualised as per the dietician, Physician and
Obstetrician.
The Statistical analysis was done by calculating mean +/- standard
deviation ,Chi square test with Yates correction, unpaired t test and P
value wherever applicable using Graph pad Instant software.
Result
Table No 1: Age wise
distribution of patients
|
Age
|
Primigravida
(%)
|
Multigravida(%)
|
|
</=20
|
38
(7.43%)
|
6
(1.17)
|
|
21-25
|
134
(26.22%)
|
113
(22.11%)
|
|
26-30
|
16
(3.13%)
|
136
(26.61%)
|
|
31-35
|
2
(0.391%)
|
59
(11.54%)
|
|
>/=36
|
0
|
7
(1.37%)
|
|
TOTAL
|
190
(37.18%)
|
321
(62.81%)
|
Maximum 321 (62.81%) patients were multigravida of which
maximum 136 (26.61%) were of age group of 26-30 years.
Table No 2: High risk
factors
|
High
risk factors
|
No.
Of patients (N=511)
|
|
Present
|
44
(8.61%)
|
|
Absent
|
467
(91.39%)
|
Out of 511 patients, high risk factors were present in 44 (8.61%)
patients, OGTT was done in first trimester. In remaining cases high
risk factors were absent and thus OGTT was done at 24-28 weeks period
of gestation.
Table No 3: Incidence of
GDM
|
No
of patients
|
GDM
|
Incidence
|
|
511
|
17
|
03.32%
|
Out of 511 patients, GDM was diagnosed in 17 patients.
Incidence of GDM in rural area of Jaipur is 03.32%.
Table No 4: Time of
detection of GDM
|
Period
of gestation
|
No
of pts of GDM
|
Percentage
|
|
1st
trimester
|
3
|
17.64%
|
|
24-28
wks
|
14
|
82.35%
|
|
Total
|
17
|
100%
|
Out of total 17 patients, maximum number of patients i.e. 14
(82.35%) were diagnosed at 24-28 wks period of gestation and 17.64% (3)
patients were diagnosed in first trimester.
Table No 5: Age Wise
distribution of GDM patients
|
Age
(years)
|
Total
|
GDM
|
Percentage
|
|
</=20
|
44
|
0
|
0
|
|
21-25
|
247
|
4
|
1.62%
|
|
26-30
|
152
|
4
|
2.63%
|
|
31-35
|
61
|
6
|
9.84%
|
|
>/=36
|
7
|
3
|
42.85%
|
|
Total
|
511
|
17
|
|
Maximum percentage of patients with GDM (42.85%) were seen
in age group of >/= 36 years, followed by 31-35 years (9.84%)
Increase in number of GDM patients were seen with increasing age. P
value was less than 0.05 thus showing that association of age with GDM
was statistically significant.
Table No 6: Gravidity
wise distribution of GDM patients
|
Gravidity
|
No. of GDM patients
|
Percentage
|
|
Primigravida (190)
|
5
|
2.63%
|
|
Multigravida(321)
|
12
|
3.73%
|
P value found to be more than 0.05, thus association of gravidity with
GDM was not statistically significant.
Table No 7: Comparison of
characteristics in GDM and non GDM groups
|
Characteristics
|
GDM (n=17)
|
Non GDM (n=494)
|
P value
|
|
Mean age +/-SD (years)
|
30.58+/-4.8
|
25.14+/-3.92
|
P<0.05
|
|
Mean gravidity+/-SD
|
5.35+/-4.27
|
2.9+/-2.01
|
P<0.05
|
|
Mean SBP(mm Hg)
|
118.9+/-7.6
|
112.35+/-8.37
|
P<0.05
|
|
Mean DBP(mmHg)
|
75+/-6.2
|
68.58+/-7.29
|
P<0.05
|
In Mean age, Mean gravidity, Mean Systolic BP, Mean Diastolic BP, the P
value is less than 0.05 which shows statistical significance.
Discussion
In our study mean age of patients was 25.32+/-4.07 years. 321 (62.81%)
patients were multigravida and 190 (37.18%) were primigravida, which
was consistent with the study done by Rajesh Rajput [2] where the mean
age of participant was 23.62+/-3.42 years & 18% were of parity
0 and 1.
It is proved that the incidence of diabetes is increasing in India [4].
In table no.2, high risk factors were present in 44 (8.61%) patients.
In our study incidence of gestational diabetes mellitus was 3.32%. It
was lower in comparision to other study because of few reason.
1. Diagnostic criteria used is diferent from other studies done by V
Seshiah , Preeti Wahi, A.P. Sawant, Kalra P as pick up rate by WHO
criteria is three times more than American diabetes association
criteria [5].
2. The incidence is lower as compared to study done by Rajesh
Rajput in Haryana using same diagnostic criteria is probably because
study population in our study was from rural area.
In rural area early marriages and early conception are known bitter
facts. Most of the patients have completed their families before 25-27
years of age. In rural areas, women do a lot of manual works inside the
house and in fields. Diet with low fat, high physical exertion
don’t allow Indian rural women to become obese which is most
important factor of GDM [6].
In our study out of 17 GDM patients 3 i.e. 17.65% were diagnosed on
first trimester and 14 i.e. 82.35% were diagnosed at 24-28 weeks. This
can be explained by the fact that a hormonal influence is maximum at
this time.
Seshiah et al found that maximum cases that 38.7% cases had glucose
intolerance before 24 weeks and 61.3% after 24 weeks. This difference
can be explained by the fact that maximum cases detected in first
trimester also includes undiagnosed type 2 DM and thus vary according
to the prevalence of type 2 DM in that area [6].
Shamshuddin et al [7] concluded that if risk factors based selective
screening is employed, it is likely that 27% of GDM women will go
undetected.
The hallmark of GDM is increased insulin resistance. Pregnancy hormones
mainly placental hormones are thought to interfere with the action of
insulin as it binds to the insulin receptor. Insulin resistance is a
normal phenomenon emerging in the second trimester of pregnancy, which
in cases of GDM progresses thereafter to levels seen in a non-pregnant
person with type 2 diabetes. It is thought to secure glucose supply to
the growing fetus. Women with GDM have an insulin resistance that they
cannot compensate for with increased production in the β-cells
of the pancreas. In a few women the physiological changes during
pregnancy result in impaired glucose tolerance which might develop
diabetes mellitus (GDM). In our study diagnosis based on high risk
factors alone would have missed 13 patients i.e. (76.47%) cases of GDM,
which is more common due to females in our rural backgrounds are not
aware of symptoms, During early pregnancy, glucose tolerance is normal
or slightly improved due to increased estrogen and progestrone causing
beta cell hyperplasia. This explains the rapid increase in insulin
level in early pregnancy, in response to insulin resistance. In the
second and third trimester, the continuous increase in the
feto-placental factors will decrease maternal insulin sensitivity [8].
Maximum incidence i.e. 42.85% was seen in age group of 36 years and
more. Mean age of GDM patients was 30.58+/-4.8 years and in non GDM
patients mean age was 25.14+/-3.92 years. Increase in incidence of GDM
was seen with increasing age (P<0.05) showing that the
association of age with GDM was statistically significant. The result
of our study was consistent with studies of Rajput R[2], Seshiah V
[6]and Singh A.[9]. A study done in Sudan showed that, there were
significant associations between presence of GDM and age ≥ 30
years (relative risk(RR) = 1.28, P = 0.016), BMI ≥ 25 Kg/m2 (RR
= 1.48, P = 0.001) and family history of diabetes mellitus (DM) (RR =
1.8, P = 0.002) [10].
Conclusion
In our study of total 511 patients, 17 patients were diagnosed as
Gestational Diabetes Mellitus thus incidence came out to be 3.32%.
Gestational diabetes generally resolves once the baby is born. GDM
poses a risk to mother and child. This risk is largely related to
uncontrolled high blood glucose levels and its consequences. The
prevalence of GDM was 12.5% and 3.8% by World Health Organization and
American Diabetes Association criteria respectively. The probability of
GDM for a parous woman increased from 2% to 21% when age increased from
20 to 40 years. [11].
Main stay of treatment is counselling before pregnancy and
multidisciplinary management, dietary changes and exercise. Self
monitoring of blood glucose levels can guide therapy. Main goal of
dietary modifications is to avoid peaks in blood sugar levels and can
be provided by spreading carbohydrate intake and using slow-release
carbohydrate sources.
Recommendation
On the basis of our study we recommend following points:
1. In all pregnant women attending first antenatal clinic,
assesment of risk factors should be done and those with high risk
factors oral Glucose Tolerance Test should be performed in first
trimester.
2. Those with negative test should be tested again at 24-28
weeks.
3. This testing should become the part of routine antenatal
investigations.
4. In India, Universal screening is recommended.
5. For doctors working in rural areas, training programs on
GDM should be arranged so as to create awareness
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
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How to cite this article?
Gupta K, Parmar M, Dubey S. Incidence of Gestational Diabetes Mellitus
in Pregnant women from rural background attending antenatal care
clinic. Int J Med Res Rev 2015;3(2):162-166. doi:
10.17511/ijmrr.2015.i2.029.